Why SHA dialysis claims may be returned: seven checks before correction

The short answer

A returned claim is not one generic failure. Start with the reason attached to the claim, then reconcile the patient and coverage details, clinical record, service dates, intervention codes, bill and technical submission before changing anything.

The checks below are drawn from Kenya's Social Health Insurance Regulations and the Digital Health Agency's AfyaLink guidance. They are documented checks, not a ranking of the most frequent return reasons. The reason attached to your facility's claim should guide the correction.

First, identify the claim's actual status

The Social Health Insurance Regulations distinguish a claim returned because it is incomplete or contains errors from a rejected claim. A returned claim should carry reasons for amendment. A rejected claim should carry reasons for rejection.

DHA's technical guidance also lists system states such as queued, approved, rejected, in-review, clinical-review and sent-for-payment-processing. Do not treat these labels as interchangeable. Record the exact status, response and reference before beginning a correction.

Seven checks before correcting the claim

1. Patient identity and eligibility. Confirm that the patient details in the treatment record match the identifiers used for the eligibility check and claim. DHA advises facilities to validate eligibility before claim submission and provides a human-readable eligibility status.
2. Coverage and preauthorisation. Check the coverage recorded for the service and any preauthorisation required for specialised care. The claim should connect the authorised service, beneficiary, provider and treatment delivered.
3. Diagnosis, intervention code and benefit rules. Confirm that the diagnosis uses a valid ICD-11 code and that the product or service uses the current SHA or PFMS intervention code. Check the renal package, facility level, access rules and session limits rather than relying on an old tariff copy.
4. Service dates and sequence. DHA requires service dates to sit within the billable period. Where interventions repeat, each needs a unique sequence correctly aligned to its start and end dates. Misalignment can result in rejection.
5. Clinical record and sign-off. Reconcile the claim with the dialysis session record, including the prescription, access, observations, medicines, consumables, complications, interventions and clinical review. Correct the source record through the facility's authorised process so the audit trail remains visible.
6. Itemised bill and total. Recalculate the bill from the claim items. DHA's submission rules state that the claim total must equal the sum of the net amounts of all items.
7. Facility, practitioner and technical references. For an electronic claim, confirm that the facility, practitioner and care-team details are valid and that every referenced resource points to the matching resource in the bundle. Preserve the original claim response and correction history.

A practical correction workflow

1. Save the original claim reference, status, reason and response date.
2. Assign the return to a named clinical, billing or system owner.
3. Compare the reason with the treatment record and the current official rule or technical guide.
4. Correct the authorised source record, then use the approved correction and resubmission workflow. Do not create a fresh duplicate with the same claim ID.
5. Recheck identity, eligibility, coverage, codes, dates, sequences, references and totals.
6. Record what changed, who approved it and when it was resubmitted.
7. Track the next response without overwriting the earlier status history.

A corrected claim may still be reviewed or rejected. The facility's goal is a complete, accurate and traceable submission, not a promise of approval.

Use the current renal package

The current tariff material describes a renal care package covering dialysis-related consultation and specialist review, nursing and dialysis services, routine laboratory investigations, medication and other dialysis protocols. It also sets access rules and session limits. Review Legal Notice 56 of 2025 on Kenya Law before using a tariff operationally.

Official technical references

DHA's AfyaLink Claims Submission Guide documents claim validation, intervention sequences, references, totals and response states. Its resubmission workflow explains how payer feedback and requested changes are handled before a claim is sent back for review.

These sources can change. This guide was reviewed against the linked official material on 23 July 2026.

Where Nanto Health fits

Certification of the system you use is a separate question from claim correction. See DHA certification in Kenya for what the Agency assesses and how to verify a vendor claim.

Nanto Health is designed to keep the dialysis session, claim-readiness checks, return reason, correction trail and follow-up status connected. SHA makes the final decision on every claim and current SHA and DHA requirements still apply.

Request a demo to see how the workflow can fit your facility's clinical and claims teams.